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Infection With Sin Nombre Hantavirus: Clinical Presentation and
Outcome in Children and Adolescents
Mary M. Ramos, MD, MPH*; Gary D. Overturf, MD*‡; Mark R. Crowley, MD*;
Robert B. Rosenberg, MD, PhD§; and Brian Hjelle, MD‡
ABSTRACT. Objective. Sin Nombre hantavirus Control and Prevention; UNM, University of New Mexico; WBC,
(SNV) is the leading causative agent of hantavirus car- white blood cell count; ECMO, extracorporeal membrane oxygen-
diopulmonary syndrome (HCPS) in the United States ation.
and Canada. Relatively few cases of HCPS have involved
children. This report describes the clinical characteristics
H
antavirus cardiopulmonary syndrome
of a series of pediatric cases of SNV infection in the
United States and Canada from 1993 through March 2000. (HCPS), also known as hantavirus pulmo-
Methods. We analyzed clinical and laboratory data on nary syndrome, is a viral zoonotic disease. It
13 patients who were 85% of patients had As described by the Centers for Disease Control
elevated levels of serum aspartate aminotransferase, ala- and Prevention (CDC),2 the HCPS prodrome typi-
nine aminotransferase, and hypoalbuminemia. Leukocy- cally consists of fever, chills, myalgia, headache, and
tosis and hemoconcentration were seen in less than one gastrointestinal symptoms. The CDC’s clinical case
third of patients at admission. HCPS developed in 12 of definition of HCPS is a febrile illness (ie, temperature
the 13 patients (92%), and 4 of those 12 died (33% case-
fatality ratio). The majority of HCPS patients (8 of 12
⬎38.3°C) characterized by bilateral diffuse interstitial
[67%]) were critically ill and required mechanical venti- edema that may radiographically resemble adult res-
lation. Extracorporeal membrane oxygenation was used piratory distress syndrome, with respiratory com-
in 2 patients, 1 of whom survived. An elevated prothrom- promise requiring supplemental oxygen, developing
bin time (>14 seconds) at admission was predictive of within 72 hours of hospitalization, and occurring in a
mortality. previously healthy person. Typical laboratory find-
Conclusions. Infection with SNV in children and ad- ings include hemoconcentration, thrombocytopenia,
olescents causes HCPS with a clinical course and mortal- left shift in the white blood cell count (WBC), neu-
ity rate similar to that described in adults. We believe trophilic leukocytosis, and circulating immunoblasts.
that early recognition of HCPS in children and adoles-
Laboratory criteria for diagnosis include detection of
cents and appropriate referral to tertiary care centers that
are experienced with HCPS are important in reducing hantavirus-specific immunoglobulin M or rising ti-
mortality. Pediatrics 2001;108(2). URL: http://www. ters of hantavirus-specific immunoglobulin G, detec-
pediatrics.org/cgi/content/full/108/2/e27; hantavirus, chil- tion of hantavirus-specific ribonucleic acid sequence
dren, adolescents, extracorporeal membrane oxygenation. by polymerase chain reaction in clinical specimens,
or detection of hantavirus antigen by immunohisto-
chemistry.2 A few cases of SNV infection leading to
ABBREVIATIONS. HCPS, hantavirus cardiopulmonary syn-
drome; SNV, Sin Nombre hantavirus; CDC, Centers for Disease febrile illness without respiratory compromise have
been reported3–5; however, the majority of cases
progress to HCPS as described above.
From the *Department of Pediatrics and ‡Department of Pathology and
Typically, the disease affects healthy adults in ru-
Tricore Reference Laboratory, University of New Mexico Health Sciences
Center, Albuquerque, New Mexico; and §Department of Pediatrics, Texas ral settings, where there is peridomestic or occupa-
Tech University Health Sciences Center, Lubbock, Texas. tional exposure to aerosols of rodent excreta. The
Received for publication Jun 28, 2000; accepted Apr 4, 2001. deer mouse (Peromyscus maniculatus) is the main ro-
Reprint requests to (B.H.) Department of Pathology, University of New dent reservoir for SNV. Most cases of HCPS have
Mexico School of Medicine, Albuquerque, NM 87131. E-mail:
bhjelle@salud.unm.edu
occurred in the southwestern United States, although
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- confirmed cases have been reported in 30 states.6
emy of Pediatrics. Because relatively few cases of SNV infection have
http://www.pediatrics.org/cgi/content/full/108/2/e27 PEDIATRICS
Downloaded from www.aappublications.org/news by guest on DecemberVol. 108 No. 2 August 2001
29, 2020 1 of 6involved children, the disease has been described RESULTS
primarily as it occurs in adults. Since the emergence As of March 31, 2000, the hantavirus database at
of HCPS in 1993, 15 (5.5%) of 274 cases reported to UNM included a total of 175 patients with SNV
the CDC have involved children ⱕ16 years of age (J. infection confirmed by serologic testing at UNM
Young, Special Pathogens Branch, CDC, personal Hospital. Of these, 13 patients (7%) were ⱕ16 years
communication, November 2000). Several case re- old. Ages ranged from 10 to 16 years (median: 14
ports of children with hantavirus infection in the years). Four of these 13 patients died (31%). The
United States have appeared in the literature.3,5,7–10 median age of those who died was 15 years (range:
Because no case fatalities have been reported in chil- 14 –15 years) versus 12.5 years (range: 10 –16 years)
dren younger than 14 years, it has been hypothesized for those who survived. Seven were female (54%)
that younger children and adolescents who are in- and 6 were male. Seven (54%) were identified as
fected with SNV are less likely to develop serious Native American; 2 (15%) were Hispanic; 1 (8%) was
illness than are older adolescents and adults. This white; information on ethnicity was not available for
report describes the clinical characteristics and out- the other 3 patients.
comes of a relatively large series of pediatric cases of Medical records of 11 of these 13 patients were
SNV infection in the United States and Canada from available for review; these patients are summarized
1993 through March 2000. in Table 1. Six patients were hospitalized at UNM
Hospital, and 2 patients were hospitalized at Texas
METHODS Tech University Health Sciences Center. For these
Since 1993, the University of New Mexico (UNM) Department patients, the database was most complete. The 2
of Pathology has maintained a database of hantavirus infection
cases documented with serologic testing performed at the UNM patients who are not included in Table 1 died, and
Health Sciences Center. The database includes patients who were their information was limited; they were 14 and 15
seen at UNM Hospital as well as those hospitalized elsewhere. years old.10
This database was reviewed for cases of hantavirus infection
involving patients who were 16 years of age or younger. Supple- Case Report
mental information was obtained by medical chart review, com-
munication with referring physicians, and in one instance from a A previously healthy 11-year-old girl from rural
published case report.8 Arizona (patient 4 from Table 1) presented to a re-
Data were extracted by 2 authors (M.M.R. and R.B.R.) using a gional hospital emergency department with a 2-day
standardized data collection form and were analyzed using SAS
software version 6.12 (SAS Institute, Inc, Cary, NC). Correlations history of headache, myalgia, chest pain, sore throat,
between mortality and symptoms before admission, physical ex- and fever. She was afebrile at the time of the visit. A
amination findings, or laboratory findings at admission were ex- throat culture was obtained, and she was discharged
amined using Fisher’s exact test (2-tail) or univariate logistic re- to home. She returned the following day with the
gression, where appropriate. Correlations between the same complaints and increasing shortness of breath.
development of respiratory failure and the aforementioned pa-
tient characteristics were examined similarly. There were no ill contacts and no known rodent
Serologic specimens were analyzed by Western blot and/or exposure. The patient’s medical history was unre-
strip immunoblot assays. Our criterion for diagnosis was the markable.
detection of immunoglobulin M antibodies to SNV nucleocapsid At the emergency department on the day of ad-
(N) antigen. In all cases, immunoglobulin G antibodies to glyco-
protein G1 antigens were present as well. Antibodies to glyco- mission, she was alert and in moderate distress with
protein G1 are specific for infection with SNV and are not seen nasal flaring. She had a temperature of 39.0°C, pulse
with infections caused by other, closely related hantaviruses.11–13 of 140 beats/min, respiratory rate of 64 breaths/min,
TABLE 1. Summary of Patient Cases
Patient Age Gender Ethnicity Place of Level of Intervention Risk Factors (Exposure) Outcome Reference
Number (Year) Residence Received
1 16 M White TX Mechanical ventilation Rural; rodent droppings Lived 7
at home
2 14 F Hispanic NM Oxygen by nasal Rural Lived
canula
3 15 F Native NM ECMO Rural Died
American
4 11 F Native AZ Mechanical ventilation Rural; collected piñón Lived
American nuts
5 12 M Native AZ Observation; no Rural; mice at home Lived
American supplemental
oxygen required
6 13 F Native NM Oxygen by nasal Rural; mice in shed Lived
American canula
7 10 M Native NM Oxygen by nasal Rural; mice in home Lived 5
American canula and family vehicle
8 15 F Native AZ Oxygen by nasal Rural; exposure to mice Lived
American canula
9 15 M Unknown Alberta, Mechanical ventilation Rural Died 8
Canada
10 11 F Native NM ECMO Rural; mouse droppings Lived
American in home
11 12 F Hispanic TX Mechanical ventilation Rural Lived
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HANTAVIRUS INFECTION IN CHILDREN
from www.aappublications.org/news by guest on December 29, 2020and a blood pressure of 132/70 mmHg. Her percu- chest radiograph from that day found minimal resid-
taneous oxygen saturation was 61% in room air. She ual patchy air space disease. By 2 days after her
had markedly decreased breath sounds bilaterally, admission, her thrombocytopenia also had resolved,
with mild retractions. Her abdominal examination to a platelet count of 164 000/mm3.
was unremarkable. Her WBC was 15 300/mm3, her She was transferred back to the referring hospital
hematocrit was 46%, and her platelet count was on the fourth hospital day. At that time, she was
74 000/mm3. The WBC differential was 52% neutro- receiving oxygen by nasal canula at 1 L/min flow
phils, 27% lymphocytes, 13% bands, and 7% mono- with a percutaneous oxygen saturation of 91%.
cytes. Her chest radiograph revealed bilateral inter-
stitial infiltrates. An initial arterial blood gas while Clinical Presentation
on 3 L/min flow of oxygen by nasal canula showed Symptoms
the following: pH 7.43, pCO2 32 torr, pO2 61 torr, and Among the 10 patients for whom information was
HCO3 21 mmol/L. available, the mean duration of symptoms before
She was intubated before transfer to UNM Hospi- hospitalization was 3.5 days (median: 3.5; range:
tal with a diagnosis of possible HCPS. Gram stain of 1–7). The most common symptoms, each present in
a tracheal aspirate obtained at the time of intubation at least 80% of patients at the time of admission,
showed few white blood cells and many Gram-neg- were, in descending order of frequency, fever, head-
ative coccobacilli and diplococci suggestive of Hae- ache, nausea or vomiting, cough, shortness of breath,
mophilus influenza infection. Before her transfer, she and myalgia (Table 2). All patients had respiratory
was treated empirically with nebulized albuterol and complaints of either cough or shortness of breath. No
intravenous methylprednisolone, ceftriaxone, genta- patients had complaints of rhinorrhea or nasal con-
micin, and erythromycin. gestion, although 4 (40%) complained of sore throat.
On admission to UNM Hospital, her temperature
was 36.9°C, her heart rate was 96 beats/min, and her Signs
blood pressure was 120/55 mmHg. Her percutane- At the time of hospital admission, 6 (55%) of 11
ous oxygen saturation was 94% on a volume-con- patients were hypoxemic with percutaneous oxygen
trolled ventilator with a positive end expiratory pres- saturations below 90% in room air; 2 patients re-
sure of 5, tidal volume of 500 mL (10 mL/kg), quired oxygen by nasal canula, and 4 patients re-
respiratory rate of 30, and an FIO2 of 0.60. Her phys- quired mechanical ventilation either before admis-
ical examination was significant for tachycardia and sion or shortly thereafter. The most common
diffuse rales bilaterally. physical examination findings on admission were
A right pleural effusion and bilateral interstitial tachypnea and fever (Table 3). Seven patients (78%)
infiltrates were present on the admission chest radio- had respiratory findings of either tachypnea or rales
graph. Laboratory studies on admission revealed a at admission. Hypotension and tachycardia were rel-
WBC of 11 400/mm3, hematocrit of 35%, platelet atively uncommon findings on admission, seen in
count of 74 000/mm3, an elevated serum aspartate 33% and 22% of patients, respectively. No patient
aminotransferase of 109 IU/L (normal: 5–35), and had purpura or petechial rash, evidence of mucosal
alanine aminotransferase of 71 IU/l (normal: 5–35). bleeding, or peripheral or periorbital edema.
Her serum lactate dehydrogenase was elevated at
1268 IU/L (normal: 300 – 600). Peripheral blood Laboratory Findings
smear analysis revealed thrombocytopenia, ⬎10% Thrombocytopenia was observed at admission in
circulating immunoblasts among the lymphoid se- all of 11 patients (100%) for whom this information
ries, and a left shift in the granulocytic series without was available (Table 4). Leukocytosis and hemocon-
significant toxic changes. These features were consis- centration were less common, each present in 3 of 11
tent with hantavirus infection. A Western blot assay patients (27%). Of the 10 patients with differential
done on admission was positive for immunoglobulin WBC at the time of admission, 6 (60%) had at least
M and immunoglobulin G antibodies against SNV. 10% band forms, 3 (30%) had metamyelocytes, and 4
The positive serologic finding was confirmed by
polymerase chain reaction analysis, which revealed TABLE 2. Symptoms in 10 Pediatric Patients With Sin Nom-
circulating SNV ribonucleic acid. bre Hantavirus Infection
The sputum culture from the referring facility
Symptom Number of
grew Moraxella species. Blood and urine cultures Patients (%)
from the referring facility were found to be negative.
A repeat sputum culture from UNM hospital sent on Fever 10 (100)
Headache 10 (100)
the day of admission found normal oral flora. Naso- Nausea or vomiting 9 (90)
pharyngeal swabs for respiratory syncytial virus, in- Cough 9 (90)
fluenza A and B, parainfluenza, and adenovirus de- Shortness of breath 8 (80)
tected by fluorescent antibodies were negative. Myalgia 8 (80)
Antibiotics were discontinued late on the day of Abdominal pain 5 (50)
Back pain 5 (50)
admission when results from the Western blot were Sore throat 4 (40)
available. The patient made a rapid recovery. She Diarrhea 4 (40)
was extubated to a face mask that delivered inspired Chest pain 3 (30)
oxygen of 40% on the second hospital day and was Chills 3 (30)
Dizziness or lightheadedness 3 (30)
weaned to oxygen by nasal canula later that day. A
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Downloaded from www.aappublications.org/news by guest on December 29, 2020 3 of 6TABLE 3. Clinical Findings at Time of Admission in 9 Pedi- history of mice around the home, and presenting
atric Patients With Sin Nombre Hantavirus Infection symptoms, the patient was tested for SNV infection.
Sign Number of Of the 12 patients with HCPS, 4 (33%) required
Patients oxygen by nasal canula and 8 (67%) required me-
(%) chanical ventilation. For the patients who required
Tachypnea* 6 (67) mechanical ventilation, the average time from the
Fever (temperature ⱖ38.0°C) 5 (56) onset of symptoms to endotracheal intubation was
Crackles or rales on lung exam 4 (44) 3.8 days (median: 4.5; range: 1– 6). Patients who were
Abdominal tenderness 4 (44)
Hypotension† 3 (33) intubated but not treated with extracorporeal mem-
Tachycardia (heart rate ⬎120 bpm) 2 (22) brane oxygenation (ECMO) were intubated for an
Cool, clammy, or mottled skin 1 (11) average of 4.6 days (median: 4; range: 2– 8). Hypo-
* Respiratory rate ⬎25 breaths/min (10 –13 years old). Respiratory tension necessitating support with vasoactive infu-
rate ⬎20 breaths/min (ⱖ14 years old). Includes 2 patients me- sions developed in 5 of the 10 HCPS patients for
chanically ventilated before admission. whom this information was available.
† Systolic blood pressure ⬍95 mm Hg (10 –13 years old). Systolic Two patients received ECMO support for hemo-
blood pressure ⬍100 mm Hg (ⱖ14 years old).
dynamic deterioration despite resuscitation with flu-
ids and vasoactive medications and mechanical ven-
tilation. ECMO therapy was initiated after 1 day and
(40%) had atypical lymphocytes. Other laboratory 3 days of symptoms, respectively, for the 2 patients
abnormalities commonly seen at admission included who received this treatment. The patient who re-
elevated levels of lactate dehydrogenase, aspartate ceived ECMO and survived required ECMO for 8
aminotransferase, and alanine aminotransferase and days and mechanical ventilation for 20 days. The
hypoalbuminemia (Table 4). other ECMO patient died after 7 days of ECMO
Three HCPS patients who were admitted to UNM support as a result of brain death caused by a pro-
hospital had peripheral blood smear analysis. All longed cardiac arrest before ECMO initiation.
had thrombocytopenia, ⬎10% circulating immuno- Only 1 patient developed significant bleeding dur-
blasts, and left shift in the granulocytic series without ing hospitalization; she developed a hemothorax as a
toxic changes. complication of thoracentesis for pleural effusion.
Five patients had an initial urinalysis at the time of Although not common at the time of admission,
admission. The median urine specific gravity was leukocytosis eventually was seen in 7 of 11 patients
1.029 g/mL (range: 1.013 to 1.041). Three of 5 patients (64%) during hospitalization, and hemoconcentra-
had proteinuria (ⱖ2⫹) on admission. Urine dipsticks tion was seen in 6 of 11 patients (55%).
were positive for blood in 2 of 5 patients; microscopic The clinical course of the 4 HCPS patients who
examination revealed ⬍3 red cells per high-power died was characterized by pulmonary edema, hypo-
field for both. tension, and ventricular arrhythmias. The ECMO
Initial chest radiographs for 10 patients revealed case fatality was described above. One patient died
interstitial or interstitial and alveolar infiltrates in 5 en route to a hospital, and 2 patients died despite
patients (50%), Kerley B lines or fluid in the fissures standard critical care. Of the group who survived,
in 2 (20%), fluffy alveolar infiltrates in 1 (10%), and the average hospital stay was 9.9 days (median: 8;
normal radiographs in 2 (20%). The 2 patients with range: 3–28) to discharge to home or transfer (in 2
initial normal chest radiographs developed intersti- cases) to a regional hospital. Those who survived
tial edema within 48 hours. were without sequelae.
Of the 13 patients, 5 became ill during the spring,
2 in the summer, 4 in the fall, and 2 patients (patients Predictors of Mortality
9 and 10 from Table 1) in the winter. The majority of An elevated prothrombin time (ⱖ14 seconds) at
patients were previously healthy and without med- admission was associated with a fatal outcome (P ⫽
ical problems. One patient was taking erythromycin .04, Fisher’s exact test). An elevated WBC (⬎13.5 ⫻
at the time of admission for acne vulgaris, and an- 103/mm3) on admission showed only a trend toward
other patient had a history of asthma. significance in association with mortality (P ⫽ .06,
Three patients were examined by medical provid- Fisher’s exact test) as did age ⱖ14 years, the median
ers and discharged to home with mistaken provi- age of our patients (P ⫽ .07, Fisher’s exact test).
sional diagnoses before returning and being admit- Symptoms before hospitalization, duration of symp-
ted. All survived. Two of the 3 developed respiratory toms, specific physical examination findings on ad-
failure and required mechanical ventilation. mission including hypoxemia, and other laboratory
findings were not associated with mortality.
Clinical Course
In 12 (92%) of the 13 patients reviewed , HCPS Predictors of Respiratory Failure
developed. One patient did not have an oxygen re- Hypotension at admission was associated with re-
quirement and so failed to meet the CDC clinical case spiratory failure requiring mechanical ventilation
description as described previously. He was a 12- (P ⫽ .02, Fisher’s exact test) as was the absence of
year-old from a rural Arizona town and had a febrile fever at admission (P ⫽ .05, Fisher’s exact test).
illness characterized by prominent abdominal pain, Symptoms before hospitalization, duration of symp-
nausea and vomiting, headache, myalgia, cough, and toms, other physical examination findings on admis-
sore throat. Because of the patient’s rural location, sion including presence of hypoxemia, and labora-
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HANTAVIRUS INFECTION IN CHILDREN
from www.aappublications.org/news by guest on December 29, 2020TABLE 4. Results of Laboratory Studies at Time of Admission in Pediatric Patients With Sin Nombre Hantavirus Infection
Number Test Admission Value
(Median [Range])
11 White cells: ⫻ 103/mm3 9.0 (3.4–59.2)
11 Hematocrit (%)
Patients 10–12 y (n ⫽ 5) 42.0 (34.9–45.2)
Males 13–16 y (n ⫽ 2) 54.3 (47.6–61)
Females 13–16 y (n ⫽ 4) 41.9 (40–48.4)
11 Platelets: ⫻ 103/mm3 67 (43–98)
10 Creatinine (mg/dL) 0.7 (0.4–3.9)
9 Prothrombin time (sec) 13.1 (11.0–29.8)
9 Partial thromboplastin time (sec) 38 (27–212)
9 Carbon dioxide (mmol/L) 20 (15–27)
9 Blood urea nitrogen (mg/dL) 10 (8–26)
8 Aspartate aminotransferase (IU/L) 98 (39–129)
8 Albumin (g/dL) 2.8 (1.2–3.5)
7 Alanine aminotransferase (IU/L) 55 (21–80)
7 Lactate dehydrogenase (IU/L) 1243 (382–1724)
6 Lactate (mmol/L) 2.5 (1.5–18.4)
tory findings were not associated with respiratory North America where the patient may present and
failure. the exposure history, the differential diagnosis may
be broad, including septicemic plague or tularemia,
DISCUSSION ehrlichiosis, leptospirosis, Colorado tick fever, re-
In this case series of pediatric patients who were 10 lapsing fever, or (“spotless”) Rocky Mountain spot-
to 16 years of age and infected with SNV, the clinical ted fever.
outcomes did not differ greatly from those described Because the initial prodrome is nonspecific, clini-
in adult cases. The case fatality ratio of 33% (4 of 12) cally diagnosing pediatric HCPS with either mild
for these pediatric patients with HCPS is comparable disease or in the early prodrome phase presents a
to the 38% case fatality rate (105 deaths in 274 cases) diagnostic challenge. SNV infection should be con-
described for HCPS overall in the United States (J. sidered in pediatric patients from rural areas, espe-
Young, Special Pathogens Branch, CDC, personal cially in western North America, who present with
communication, November 2000). As in adult cases, fever, headache, myalgia, and respiratory and gas-
the majority of the 12 pediatric HCPS patients de- trointestinal symptoms, particularly if there is a his-
scribed herein (8 of 12 [67%]) were critically ill and tory of possible rodent exposure. Infection is most
progressed to respiratory failure. Consistent with the common from spring through fall.
newer designation of hantavirus cardiopulmonary If HCPS is suspected, then a complete blood count
syndrome, at least half of the patients developed with platelet count should be obtained. Thrombocy-
cardiogenic shock and required inotropic support. topenia is a key laboratory feature of HCPS. If throm-
The most frequent prodromal symptoms of our bocytopenia or a rapidly decreasing platelet count is
pediatric patients, particularly fever, headache, my- found, peripheral blood smear analysis and serology
algia, and respiratory and gastrointestinal com- testing should be performed. At UNM hospital, a
plaints, are comparable to those described in adults peripheral blood smear with 4 of the 5 criteria
with HCPS. One exception is the common complaint (thrombocytopenia, ⬎10% circulating immunoblasts
of sore throat, seen in almost half of our patients, among the lymphoid series, left shift of granulocytic
which has been described as an infrequent symptom series, without toxic changes, and hemoconcentra-
among adults with HCPS.14,15 Typical clinical labo- tion) has been found to have a positive predictive
ratory findings early in the course include thrombo- value of 90% for HCPS. All cases with 5 of the 5
cytopenia and elevated liver enzymes and lactate criteria have been confirmed serologically (K. Fou-
dehydrogenase. A left shift in the granulocytic series car, Department of Pathology, UNM School of Med-
without toxic changes is often present, but leukocy- icine, personal communication, September 2000).
tosis and hemoconcentration are relatively late find- Pending results, patients need to be monitored
ings, observed in ⬎50% of cases during the course of closely for signs of cardiopulmonary compromise,
illness. which can develop rapidly with the onset of pulmo-
The differential diagnosis for pediatric patients nary edema. There is not yet a reliable early indicator
who present with fever, headache, myalgia, and re- as to which patients will develop more severe dis-
spiratory and gastrointestinal symptoms is broad. ease.
Viral and bacterial pneumonia, sepsis syndrome Because of the high proportion of HCPS patients
with adult respiratory distress syndrome, and acute who become critically ill and the rapid deterioration
gastroenteritis are among the more likely clinical seen in many HCPS patients, we believe that early
syndromes. The authors are aware of patients admit- transfer to a tertiary care center that is capable of
ted to rule out HCPS and who subsequently had the providing critical care and ECMO support should be
diagnosis of viral respiratory illness (eg, respiratory strongly considered. In our experience, ECMO seems
syncytial virus), streptococcal pharyngitis, and sepsis to be beneficial in the support of critically ill patients
attributable to S aureus. Depending on the region of with severe HCPS,16 including pediatric patients.
http://www.pediatrics.org/cgi/content/full/108/2/e27
Downloaded from www.aappublications.org/news by guest on December 29, 2020 5 of 6ECMO has been used in the treatment of 26 HCPS tious conditions under public health surveillance. MMWR Morb Mortal
Wkly Rep. 1997;46:1–55
patients at UNM Hospital with a survival rate of 69% 3. Armstrong LR, Bryan RT, Sarisky J, et al. Mild hantaviral disease caused
(M.R. Crowley, unpublished data). Criteria for the by Sin nombre virus in a four-year-old child. Pediatr Infect Dis J. 1995;
initiation of ECMO at UNM Hospital include param- 14:1108 –1110
eters consistent with 100% mortality from our expe- 4. Zavasky DM, Hjelle B, Peterson MC, et al. Acute infection with Sin
rience with HCPS. nombre Hantavirus without pulmonary edema. Clin Infect Dis. 1999;29:
664 – 666
5. Ramos MM, Hjelle B, Overturf GD. Sin Nombre hantavirus disease in a
CONCLUSION 10-year-old boy and his mother. Pediatr Infect Dis J. 2000;19:248 –250
HCPS is an uncommon serious viral zoonosis that 6. Centers for Disease Control and Prevention. Update: Hantavirus pul-
causes respiratory failure and cardiovascular insta- monary syndrome—United States, 1999. MMWR Morb Mortal Wkly Rep.
1999;48:521–525
bility in children and carries a high case fatality rate 7. Rosenberg RB, Waagner DC, Romano MJ, et al. Hantavirus pulmonary
of 33%. HCPS in pediatric patients has a similar syndrome treated with inhaled nitric oxide. Pediatr Infect Dis J. 1998;17:
presentation and outcome to that described in adults. 749 –752
HCPS occurs mainly in the rural western United 8. Lee BE, Joffe AR, Vaudry W. Hantavirus pulmonary syndrome: report
States, but cases have been reported nationwide. Be- of the first Canadian paediatric case. Can J Infect Dis. 1998;9:319 –321
9. Khan AS, Ksiazek TG, Zaki SR, et al. Fatal Hantavirus pulmonary
cause of the high mortality and often fulminant de- syndrome in an adolescent. Pediatrics. 1995;95:276 –280
terioration of pediatric HCPS patients, medical pro- 10. Rawlings JA, Torrez-Martinez N, Neill SU, et al. Cocirculation of mul-
viders who care for children should familiarize tiple Hantaviruses in Texas, with characterization of the small (s) ge-
themselves with the clinical features of HCPS. Early nome of a previously undescribed virus of cotton rats (Sigmodon hispi-
dus). Am J Trop Med Hyg. 1996;55:672– 679
recognition of this disease with prompt referral to 11. Hjelle B, Jenison S, Torrez-Martinez N, et al. Rapid and specific detec-
tertiary care centers that have experience with HCPS tion of Sin Nombre virus antibodies in patients with hantavirus pulmo-
likely will improve outcome and reduce mortality. nary syndrome by a strip immunoblot assay suitable for field diagnosis.
J Clin Microbiol. 1997;35:600 – 608
ACKNOWLEDGMENTS 12. Jenison S, Yamada T, Morris C, et al. Characterization of human anti-
body responses to Four Corners hantavirus infections among patients
This study was supported by Public Health Service Grant RO1
with hantavirus pulmonary syndrome. J Virol. 1994;68:3000 –3006
AI 41692 and by the Defense Advanced Research Projects Agency.
13. Bharadwaj M, Nofchissey R, Goade D, Koster F, Hjelle B. Humoral
We thank J. Rawlings, F. Koster, R. Servi, D. Goade, J. Young,
immune responses in the hantavirus cardiopulmonary syndrome. J In-
and J. Hutchinson for their help in collecting data; C. Qualls for
fect Dis. 2000;182:43– 48
assistance with statistics; and TriCore Laboratories for technical
14. Duchin JS, Koster FT, Peters CJ, et al. Hantavirus pulmonary syndrome:
assistance.
a clinical description of 17 patients with a newly recognized disease.
N Engl J Med. 1994;330:949 –955
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HANTAVIRUS INFECTION IN CHILDREN
from www.aappublications.org/news by guest on December 29, 2020Infection With Sin Nombre Hantavirus: Clinical Presentation and Outcome in
Children and Adolescents
Mary M. Ramos, Gary D. Overturf, Mark R. Crowley, Robert B. Rosenberg and Brian
Hjelle
Pediatrics 2001;108;e27
DOI: 10.1542/peds.108.2.e27
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Downloaded from www.aappublications.org/news by guest on December 29, 2020Infection With Sin Nombre Hantavirus: Clinical Presentation and Outcome in
Children and Adolescents
Mary M. Ramos, Gary D. Overturf, Mark R. Crowley, Robert B. Rosenberg and Brian
Hjelle
Pediatrics 2001;108;e27
DOI: 10.1542/peds.108.2.e27
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/108/2/e27
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2001
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